Surgical Errors: Wrong-Patient And Wrong-Site Surgeries


All surgeries carry risk of error.  However, some of these errors are preventable.  Wrong-patient and wrong-site surgery is an example of such a preventable error.  The Archives of Surgery published a study by Denver researchers who analyzed 27,370 physician-reported adverse events from a database compiled by Colorado Physician Insurance Company and found that doctors in Colorado operated on the incorrect body part 107 times and performed a surgery on the wrong person 25 times.  Of these procedures twenty percent of wrong-patient procedures and 38 percent of wrong-site surgeries lead to the patient experiencing significant harm.  In one case the patient died after the wrong body part was operated on by the doctor.  The occurrence of this went up between 2002 and 2007.

In order to prevent such errors from occurring some guidelines that hospitals can adopt have been created.  These guidelines involved the creation of a pre-operative verification process, marking the operative site, and a “time-out” just prior to starting the procedure.

Pre-operative Verification Process

Based on each hospitals specific circumstance, a methodology of pre-procedure verification and site marking should be created.  The verification of the correct patient, procedure, and site should occur while the patient is still awake and aware (if it is possible).  This can occur:

  • At the time the surgery or procedure is scheduled.
  • During pre-admission and testing.
  • When the patient is admitted or has entered the facility.
  • When the responsibility for care of the patient is transferred to another care giver.
  • Prior to the patient leaving the preoperative are or as they enter the procedure/surgical room.

A preoperative verification checklist could make this process easier.  Such a checklist would also help with review of relevant documentation, ensure that images are properly labeled and displayed, and that required implants and special equipment is available.

Marking the Operative Site

Doctors also need to make sure that the operative site is properly marked.

  • The mark should be at or near the incision site.  It is important that there are no marks on any non-operative site(s) unless another aspect of care requires it.
  • The mark should be unambiguous.
  • After the patient has been prepped and draped, the mark should still be visible.
  • The marker needs to be sufficiently permanent so that it remains visible after the skin has been prepped.
  • The method of marking an operative site should be consistent throughout the organization.
  • The mark should be made by someone who is familiar with the patient and is involved with the patient’s procedure, such as a surgeon, nurse practitioner, or physician assistants.
  • A final verification of the mark should be done during “time-out.”

“Time-Out” Just Prior to the Start of the Procedure

Prior to the commencement of the procedure, a time out should be conducted.  The entire operative team should be involved, using active communication, be documented briefly (such as in a checklist), and should include:

  • Correct patient identity.
  • Correct side and site.
  • Agreement on the procedure to be done.

Additionally, there should be a system and process in place so that differences in staff responses during “time-out” can be reconciled.

Despite the implementation of guidelines and safeguards major mistakes continue to be made.  If you or a loved one has been the victim of a surgical error you should call a medical malpractice attorney as soon as possible.

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